=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043380660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL VAN DUREN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 02/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 7TH ST
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98356-9430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-899-0536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1003
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98356-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-899-0536
-----------------------------------------------------
Fax | 925-957-5401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G60941
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | G60941
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------